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Management of clinical chorioamnionitis: an evidence-based approach.

American journal of obstetrics and gynecology
December 1, 2020
Agustin Conde-Agudelo et al. (4 authors)
Journal ArticleResearch Support, N.I.H., ExtramuralResearch Support, N.I.H., IntramuralReviewHuman Study
Study Details

Study Goal

The researchers aimed to evaluate the potential of N-acetylcysteine as an antioxidant and anti-inflammatory agent to reduce neonatal morbidity and mortality in patients with clinical chorioamnionitis.

Results Summary

The study suggests that antenatal administration of N-acetylcysteine may reduce neonatal morbidity and mortality, but well-powered randomized controlled trials are needed to confirm these effects.

Population

Pregnant individuals with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks.

Effective Dosage

Not specified

Duration

Not specified

Interactions

None mentioned

Extracted Claims (13)
InterventionDirectionEndpointPopulationDosageImpactClaim #
ampicillin combined with gentamicin
neutral
treatment of clinical chorioamnionitis
patients with clinical chorioamnionitis
-
is the first-line antimicrobial regimen
#1
clindamycin
neutral
-
patients at the time of umbilical cord clamping during cesarean delivery
-
should be received
#2
additional antibiotic therapy
no change
-
patients after vaginal or cesarean delivery
-
does not appear to be necessary
#3
antipyretic agents, mainly acetaminophen
no change
-
patients with clinical chorioamnionitis
-
can be received even though there is no clear evidence of their benefits
#4
antenatal corticosteroids for fetal lung maturation
increase
fetal lung maturation
patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation
-
has an overall beneficial effect on the infant
#5
magnesium sulfate for fetal neuroprotection
increase
fetal neuroprotection
patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation
-
has an overall beneficial effect on the infant
#6
vaginal delivery
neutral
-
patients with clinical chorioamnionitis
-
is the safer option
#7
time interval between the diagnosis of clinical chorioamnionitis and delivery
no change
most adverse maternal and neonatal outcomes
patients with clinical chorioamnionitis
-
is not related to
#8
oxytocin
increase
uterine activity
patients with clinical chorioamnionitis
higher dose
may require a higher dose to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation
#9
continuous electronic fetal heart rate monitoring
no change
-
patients with clinical chorioamnionitis
-
benefit is unclear
#10
antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole
increase
coverage against microorganisms
patients with clinical chorioamnionitis
-
provides coverage against the most commonly identified microorganisms
#11
vaginal cleansing with antiseptic solutions before cesarean delivery
decrease
endometritis and, possibly, postoperative wound infection
patients before cesarean delivery
-
aim of decreasing the risk
#12
antenatal administration of N-acetylcysteine
decrease
neonatal morbidity and mortality
patients with clinical chorioamnionitis
-
to reduce
#13
Abstract

This review aimed to examine the existing evidence about interventions proposed for the treatment of clinical chorioamnionitis, with the goal of developing an evidence-based contemporary approach for the management of this condition. Most trials that assessed the use of antibiotics in clinical chorioamnionitis included patients with a gestational age of ≥34 weeks and in labor. The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period. In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping. The administration of additional antibiotic therapy does not appear to be necessary after vaginal or cesarean delivery. However, if postdelivery antibiotics are prescribed, there is support for the administration of an additional dose. Patients can receive antipyretic agents, mainly acetaminophen, even though there is no clear evidence of their benefits. Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant. However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate. Once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age. Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications. The time interval between the diagnosis of clinical chorioamnionitis and delivery is not related to most adverse maternal and neonatal outcomes. Patients may require a higher dose of oxytocin to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation. The benefit of using continuous electronic fetal heart rate monitoring in these patients is unclear. We identified the following promising interventions for the management of clinical chorioamnionitis: (1) an antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole that provides coverage against the most commonly identified microorganisms in patients with clinical chorioamnionitis; (2) vaginal cleansing with antiseptic solutions before cesarean delivery with the aim of decreasing the risk of endometritis and, possibly, postoperative wound infection; and (3) antenatal administration of N-acetylcysteine, an antioxidant and antiinflammatory agent, to reduce neonatal morbidity and mortality. Well-powered randomized controlled trials are needed to assess these interventions in patients with clinical chorioamnionitis.

Medical Subject Headings (MeSH)
AcetylcysteineAdrenal Cortex HormonesAmpicillinAnti-Bacterial AgentsAnti-Infective Agents, LocalAntioxidantsAntipyreticsCeftriaxoneCesarean SectionChorioamnionitisClarithromycinClindamycinDelivery, ObstetricEndometritisEvidence-Based MedicineFemaleGentamicinsGestational AgeHumansMagnesium SulfateMetronidazolePractice Guidelines as TopicPregnancyPuerperal InfectionTocolytic Agents
Study Links
Quality Scores
SafetyNot Assessed
Efficacy70/10
Quality80/10
Citation Metrics
Total Citations61
Citations/Year12.2
Relative Citation Ratio5.58
NIH Percentile94.2%
Research Impact Scores
APT Score0.95
Weight Score2.63
Normalized Score0.64
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